HospitalInspections.org

Based on a review of facility documentation and staff interview, the facility failed to provide documented evidence that 2 of 9 patients [Patients #4 and 8], or their legally authorized representatives, received an explanation of their patient rights in a manner that they could understand prior to discharge.


Findings were:

Facility policy #RTS-02 entitled "Patient Rights Texas," effective date 1/11/16, included the following:
"Every client shall receive a written copy of the Patient's Bill of Rights. The patient will sign the "Acknowledgement of Rights" form stating that they reviewed and understand their rights. The patient rights form will be available in Spanish, as well as English ...
Intake Coordinator ...Shall orally review the Patient Rights with the patient and family/parent or conservator of a minor (when applicable) and have the patient sign the "Acknowledgment of Rights" form ...
Nursing Staff/Social Services Staff ...If a patient is disoriented or in a state that impairs cognition at the time of entry, he/she is informed of his/her rights at an appropriate time during care, treatment, and services. Periodically, attempts to review the patient rights with the new patient admit will be documented ...Documentation of attempted explanation of rights will be upon admit, within 24 hours, 72 hours and on each successive treatment review(s) date(s) until such a time the patient is able to voice understanding of his/her rights or throughout the patient's stay. Each documentation will include the date of attempted communication, the reason for the repeated attempt, the signature of the person who explained the rights and a witness to the attempted communication ...
When the patient receiving services is unable or unwilling to sign the document which confirms that rights have been orally communicated, a brief explanation of the reason should be entered onto that document along with the signatures of the person who explained the rights and a third-party witness.
If the patient does not appear to understand the rights explanation, staff will attempt to provide another explanation periodically until understanding is reach or until discharge. The necessity for repeating the rights communication process will be documented, signed, and dated by staff ...
Patient/Client Rights ...
[You have] The right to have these rights and any additional rights explained aloud in a way the person served can understand within 24 hours of admission ...and upon request ..."

Patient #4 was admitted to Oceans Behavioral Health Hospital of Katy on 7/16/18 at 10:00 p.m. It was documented that the patient spoke only Spanish. It was also documented that he "refused" to the receipt of patient rights upon admission on 7/16/18 at 7:50 p.m. The form acknowledging receipt of the patient rights which the staff member signed was in English. There was no documentation of additional attempts to explain his patient rights to him and obtain his signature acknowledging receipt and understanding. There was no documented evidence that information was provided to him in Spanish regarding these matters.

Patient #8 was admitted to the hospital on 7/17/18 at 5:45 p.m. He did not sign the form acknowledging receipt of a copy of the Patient Bill of Rights. There was no documented evidence of facility staff having again approached the patient to explain his rights and have him sign for receipt and understanding.

All of the above findings were discussed in an interview with the Staff #1, facility administrator, on the afternoon of 8/16/18 in the facility conference room. No additional evidence of compliance was submitted.

Based on a review of facility documentation and staff interviews, the facility failed to ensure each patient was appropriately reassessed for a worsening medical condition by nursing staff. This resulted in 1 of 1 such patients experiencing a decline in physical status, which ultimately led to his transfer to an acute care hospital emergency room [Patient #1].


Findings were:

Facility policy #CS-02 entitled "Treatment Planning: Integrated/Multidisciplinary," revised 5/1/17, included the following:
"POLICY: ...Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment ...
PROCEDURE:
1. The admitting physician is responsible for providing the following:
Prescribing treatment modalities for the initial plan of care ...
2. The admitting nurse in responsible for the following:
Formulating the initial treatment plan based on physician's orders/initial plan and findings and conclusions from the Pre-admission Assessment, Nursing Assessment ...
Ensure that this preliminary plan of care addresses presenting needs ..."

Facility policy #NSG-02 entitled "Nursing," revised 10/1/17, included the following:
"PURPOSE: ...
To provide specific information regarding medications, treatments, and observations which reflect the care and progress of the patient.
To increase communication among the various disciplines providing care to the patient ...
PROCEDURE: ...
Routine ...
Documents pertinent, factual information, including assessment, education and outcome ..."

A review of the medical record of Patient #1 revealed he was admitted to Oceans Behavioral Health Hospital of Katy on 10/9/17 after transfer from an acute care hospital. A history & physical examination on 10/9/17, no time, included the following:
"68 yo [male] admitted from [hospital name] ...manic & bizarre behavior, lack of sleep, excessive spending money, sexually inappropriate behavior. Has been noncompliant [with] his medications. Significant for PMH (past medical history) as listed below ...
Physical Exam: ...
Skin: some open blisters BLE (bilateral lower extremities) ...
Assessment and Plan: (includes each medical problem, a review of patient information, impressions, findings, differential diagnosis and recommendations for the plan of care):
Bipolar D/O (disorder) - psych primary team to eval/treat cont (continue) meds as per recommendation. BLE (bilateral lower extremity) edema - will resume Lasix 40 mg x 2 days then 20mg qd. Hx DVT BLE (deep vein thrombosis bilateral lower extremities) - on Coumadin. Monitor Pt/INR. HTN (hypertension) - on Cozaar ..."

A nursing skin assessment on 10/9/17 at 4:20 a.m. included findings of bilateral lower extremity edema noted as "hot, edemous [sic], red, weeping ..."

From 10/11/17 (7p-7a shift) until 10/20/17, the date the patient was transferred to an acute care hospital, nursing assessments did not address or minimally addressed the patient's worsening cellulitis/leg edema.

Nursing skin assessments were documented as follows:
10/11/17 at 10: 20 p.m. -the skin assessment section included only the written word "Bruising."
10/12/17 at 8:00 a.m. - the patient's skin assessment was not addressed at all.
10/12/17 at 10:40 p.m. -the skin assessment section included only the written word "Bruises."
10/13/17 at 9:30 a.m. -the skin assessment section included only the written word "Bruises." A note at that time read as follows: "Pt visible in dayroom, socialize [sic] well pt calm, cooperative, denies SI (suicidal ideation), AVH (auditory/visual hallucinations), & pain. Denies pain. Will cont to evaluate & monitor for changes."
10/13/17 at 8:45 p.m. - the skin assessment included only the written word "Bruises."
10/14/17 at 8:30 a.m. -for the skin assessment section, the option "Other" was checked and next to that was written the word "clean." The nurse checked "Other" under "wound(s)" and wrote "none."
10/14/17 at 10:15 p.m. - a nursing note included, "Pt's both legs swollen with no discharge noted. No physical distress ..."
10/15/17 at 8:43 p.m. - in the wound assessment area, the nurse checked "Other" and wrote "none."
10/16/17, no time (blank) - the nurse checked "Other" and wrote "Rt leg swelling being [illegible] ..."
10/16/17 at 10:40 p.m. - the entire skin assessment section was left completely blank.
10/17/17 at 7:45 a.m. - the entire skin assessment section was left completely blank.
10/17/17 at 10:15 pm. - the entire skin assessment section was left completely blank
10/18/17 at 5:00 p.m. - the nurse checked the option, "Other," and wrote "BL edematous" possibly (illegible).
10/18/17 at 8:52 p.m. - under skin assessment section, the nurse entered, "Other: none..."
10/19/17 at 5:30 p.m. - the only skin assessment entry was the hand-written word, "Bruises."
10/19/17 at 8:55 p.m. - the nursed entered, "Other: None ..."
10/20/17 at 7:45 a.m. - the skin assessment section was left completely blank.


10/20/17 at 7:30 p.m., a nursing note read as follows: "Order received from [name] ...to transfer patient to ER for worsening cellulitis ..."
10/20/17 at 7:50 p.m. - "Health Quest EMS called awaiting arrival ..."
10/20/17 at 8:14 p.m. - "[spouse] notified ..."
10/20/17 at 8:15 p.m. - "Report given to Joseph RN at Memorial Hermann ER ..."
10/20/17 at 8:25 p.m. - "Pt transfer to [hospital name] ER via health quest in stable condition. BP 137/75, P 78, R 20, Temp 98.2, O2 Sat 98.9 room air ..."
10/20/17 at 8:30 p.m. - "[Name], DON notified ..."
10/20/17 at 8:40 p.m. - "[Name], the psychiatrist notified ..."

There were no other nursing notes or assessments available for surveyor review other than those noted above which addressed the patient's bilateral lower extremity edema and cellulitis.

Relevant physician's orders included the following:
10/13/17 at 10:50 a.m. - "Medical consult for [right] leg swelling. Send by hospital for left leg cellulitis ..."
10/13/17 at 11:00 a.m. - "Cancel sending pt out to hospital ..."
10/13/17 at 11:11 a.m. - "Start Keflex 500 mg BID x 7 days. Start Rocephin 1g IM x 1 dose ..."
10/13/17 at 11:12 a.m. - " ...Cleanse area [with] NS 0.9% (normal saline) leave open to air ..."
10/15/17 at 2:00 p.m. - " DC Lasix 40 mg q daily Start Lasix 40 mg po BID Dx (diagnosis): BLE edema worse Cleanse BLE open blisters [with] NS apply ...TAO ointment - apply compression wraps, Kerlix & Coban drsg, [change] q daily - light compression ..."
10/20/17 at 7:30 p.m. - "Please send pt to ER, worsening cellulitis RLE ..."

The patient was transferred to the emergency room of an acute care hospital on 10/20/17. He did not return to Oceans Behavioral Health Hospital of Katy.


All the above findings were discussed and confirmed in an interview with Staff #1, facility Administrator, Staff #2, Director of Nursing, and Staff #3, Director of Quality, on the morning of 8/15/18 at 11:45 a.m. in the facility conference room. No additional evidence of compliance was submitted.

Based on a review of facility documentation and staff interview, the facility failed to ensure:

1) Each patient was given the right to participate in the development of his/her own individualized treatment plan for 6 of 9 patients [Patients #1, 2-4, 6, and 8]

2) Physician involvement in treatment planning for 1 of 9 patients [Patient #1]

3) Medical issues were addressed in a treatment plan individualized to each patient for 1 of 1 patients [Patients #1]

4) Information about psychoactive medication was provided to the patient prior to his/her being administered the medication for 1 of 9 patients [Patients #4]


Findings were:

The facility failed to ensure:
1) Each patient was given the right to participate in the development of his/her own individualized treatment plan for 6 of 9 patients [Patients #1, 2-4, 6, and 8].

Facility policy #CS-02 entitled "Treatment Planning: Integrated/Multidisciplinary," revised 5/1/17, included the following:
"POLICY: ...Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment ...
PROCEDURE:
4. The treatment plan shall be signed by all members of the IDT - interdisciplinary team. If the patient is unable and/or unwilling to sign the treatment plan, the reason or circumstances of such inability or unwillingness shall be documented in the patient's medical record ..."

A review of patient clinical records included the following:

A Multidisciplinary Integrated Treatment Plan was initiated for Patient #1 on 10/9/17 at 6:00 a.m. The plan form included a place for the patient to sign indicating his participation. The signature line was blank. The form also included an area to document why the patient was unable to participate in the development of the treatment plan. That, too, was blank.

An update of Patient #2's treatment plan on 7/24/18 at 10:35 a.m. revealed the following section left completely blank:
"Individualized Patient Treatment Planning:
Patient ...Did ...Did not ...understand treatment goals for the next certified period.
Patient ...Agreed ...Disagreed ...with individual treatment plan as developed.
Patient ...Declines ...Wishes to include the following treatment goals ... [line provided] ..."
None of the above options were circled or addressed in the update.

Patient #3 was admitted to the facility on 6/21/18 at 11:55 p.m. with a diagnosis of major depressive disorder, recurrent, severe with psychosis. She was unable to sign consents for treatment or her treatment plan on admission. It was noted on these items: "Pt unable to sign due to dementia." No attempt to contact her legally authorized representative (LAR) had been documented. Yet, it was documented Patient #3 had given verbal consent on 6/22/18 at 6:30 a.m. to receive psychoactive medications such as Risperdal and lorazepam.

A Multidisciplinary Integrated Treatment Plan was initiated for Patient #4 on 7/16/18 at 12:20 p.m. It was signed by the physician on 7/17/18 at 1:00 pm. The form included a place for the patient to sign indicating his participation in the plan. The signature line was blank. The form also included an area to indicate why the patient was unable to participate in the development of the treatment plan. That, too, was blank. The patient was documented to speak only Spanish. The Treatment Plan form was in English. There was documentation of interpreter services used.

An update to the treatment plan of Patient #4 was signed by the physician on 7/24/18 at 11:00 a.m. The update was not signed by the patient as participating in the plan, and no reason was documented for his not signing. This form was in English. There was no documentation of interpreter services used.

Patient #6 was admitted to the facility on 7/30/18. A Multidisciplinary Integrated Treatment Plan was started for her on 7/30/18. The form included a place for the patient to sign indicating her participation in the plan. The signature line was blank. The form also included an area to indicate why the patient was unable to participate in the development of the treatment plan. That, too, was blank.


The facility failed to ensure:
2) Physician involvement in treatment planning for 1 of 9 patients [Patient #1].

Facility policy #CS-02 entitled "Treatment Planning: Integrated/Multidisciplinary," revised 5/1/17, included the following:
"POLICY: ...Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment ...
PROCEDURE:
1. The admitting physician is responsible for providing the following:
Prescribing treatment modalities for the initial plan of care.
Documenting the assessment and physician's orders in medical record.
Providing direction to the multi-disciplinary team in the formulation of treatment planning goals, objectives and clinical interventions ...
4. The treatment plan shall be signed by all members of the IDT - interdisciplinary team. If the patient is unable and/or unwilling to sign the treatment plan, the reason or circumstances of such inability or unwillingness shall be documented in the patient's medical record ...
6. Multi-Disciplinary Team Members or Designee is responsible for:
Attending Treatment Planning Team ..."

Facility policy #BLAW-03 entitled "Medical Staff Rules and Regulations," no effective date though noted as approved by the governing body, included the following:
" ...General Conduct of Care ...
8 ...d. The attending LIP's (licensed independent practitioners) [sic] participate in the multidisciplinary treatment team. Through psychiatric and psychological evaluation of the patient, and provision of psychiatric/psychological services and direction of the treatment team. [sic] There is physician involvement in and approval in and approval of the multidisciplinary team plan ..."

A Multidisciplinary Integrated Treatment Plan was started for Patient #1 on 10/9/17 at 6:00 a.m. It was never signed by a physician. The form included a place for the patient to sign indicating his participation in the plan. The signature line was blank. The form also included an area to indicate why the patient was unable to participate in the development of the treatment plan. That, too, was blank.


The facility failed to ensure:
3) Medical issues were addressed in a treatment plan individualized to each patient for 1 of 1 patients [Patients #1].

Facility policy #CS-02 entitled "Treatment Planning: Integrated/Multidisciplinary," revised 5/1/17, included the following:
"POLICY: ...Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment ...
PROCEDURE:
1. The admitting physician is responsible for providing the following:
Prescribing treatment modalities for the initial plan of care ....
Providing direction to the multi-disciplinary team in the formulation of treatment planning goals, objectives and clinical interventions ...
2. The admitting nurse in responsible for the following:
Formulating the initial treatment plan based on physician's orders/initial plan and findings and conclusions from the Pre-admission Assessment, Nursing Assessment ...
Ensure that this preliminary plan of care addresses presenting needs ..."

A review of the clinical record of Patient #1 revealed he was admitted to Oceans Katy on 10/9/17 after transfer from an acute care hospital. A history & physical examination on 10/9/17, no time, included the following:
"68 yo [male] admitted from Ben Taub Hosp [twice] manic & bizarre behavior, lack of sleep, excessive spending money, sexually inappropriate behavior. Has been noncompliant [with] his medications. Significant for PMH (past medical history) as listed below. Here for psychotic & medication evaluation ...
Physical Exam: ...
Skin: some open blisters BLE (bilateral lower extremities) ...
Assessment and Plan: (includes each medical problem, a review of patient information, impressions, findings, differential diagnosis and recommendations for the plan of care):
Bipolar D/O (disorder) - psych primary team to eval/treat cont (continue) meds as per recommendation. BLE edema - will resume Lasix 40 mg x 2 days then 20mg qd. Hx DVT BLE (deep vein thrombosis bilateral lower extremities) - on Coumadin. Monitor Pt/INR. HTN (hypertension) - on Cozaar ..."

A nursing skin assessment performed on Patient #1 on 10/9/17 at 4:20 a.m. included findings of bilateral lower extremity edema noted as "hot, edemous [sic], red, weeping ..."

Relevant physician's orders included the following:
10/13/17 at 10:50 a.m. - "Medical consult for [right] leg swelling. Send by hospital for left leg cellulitis ..."
10/13/17 at 11:00 a.m. - "Cancel sending pt out to hospital ..."
10/13/17 at 11:11 a.m. - "Start Keflex 500 mg BID x 7 days. Start Rocephin 1g IM x 1 dose ..."
10/13/17 at 11:12 a.m. - " ...Cleanse area [with] NS 0.9% (normal saline) leave open to air ..."
10/15/17 at 2:00 p.m. - " DC Lasix 40 mg q daily Start Lasix 40 mg po BID Dx (diagnosis): BLE edema worse Cleanse BLE open blisters [with] NS apply ...TAO ointment - apply compression wraps, Kerlix & Coban drsg, [change] q daily - light compression ..."
10/20/17 at 7:30 p.m. - "Please send pt to ER, worsening cellulitis RLE ..."

On 10/20/17 at 7:30 p.m., a nursing note read as follows: "Order received from [name] ...to transfer patient to ER for worsening cellulitis ..."
10/20/17 at 7:50 p.m. - "Health Quest EMS called awaiting arrival ..."
10/20/17 at 8:14 p.m. - "[spouse] notified ..."
10/20/17 at 8:15 p.m. - "Report given to Joseph RN at Memorial Hermann ER ..."
10/20/17 at 8:25 p.m. - "Pt transfer to Memorial Hermann Katy ER via health quest in stable condition. BP 137/75, P 78, R 20, Temp 98.2, O2 Sat 98.9 room air ..."
10/20/17 at 8:30 p.m. - "[Name], DON notified ..."
10/20/17 at 8:40 p.m. - "[Name], the psychiatrist notified ..."

A Multidisciplinary Integrated Treatment Plan was started for Patient #1 on 10/9/17 at 6:00 a.m. It was never signed by a physician.

The problem list of the treatment plan included a goal noted as " ...10/9 Alteration in Health Maintenance ..." This problem included only goals for managing the patient's hypertension and addressing his ability to comply with his prescribed regime. There was no mention of the patient's leg edema/cellulitis. Thus the treatment plan did not address his medical issues documented on admission and for which he was eventually sent to an emergency department of an acute care hospital.


The facility failed to ensure:
4) Information about psychoactive medication was provided to the patient prior to his/her being administered the medication for 1 of 9 patients [Patients #4].

Facility policy #MM-02 entitled "Psychoactive Medication Administration/Consent - Texas," last revised 2/1/17, included the following:
"PURPOSE:
To ensure the safe, appropriate, and accurate administration and handling of medications. To provide a process for ensuring patients and/or families are involved in decisions about care, treatment and services ...
POLICY ...
If psychoactive medications are prescribed by a LIP (licensed independent practitioner), a written informed consent must be obtained from the patient or legally authorized representative ...
2. The initiation of new psychoactive medications during admission requires a signed informed consent form ..."

Patient #4 was admitted to Oceans Behavioral Health Hospital of Katy on 7/16/18 at 10:00 p.m. It was documented upon admission that the patient spoke only Spanish.

Consents to receive the psychoactive medications of Seroquel (an anti-psychotic medication) and Depakote (an anti-epileptic medication often used for mood stabilization) were not signed by the patient. A staff member signed the consent on 7/20/18 at 4:23 p.m., and wrote "agrees with taking meds unable to sign." The verbal consent of the patient was documented as "witnessed" by another staff member who signed the form on 7/20/18 at 9:45 a.m. Thus, the witness to the patient's verbal consent signed approximately 6.5 hours prior to the staff person's supplying the medication information to the patient. It was circled that only an "oral explanation" was provided for the medications. "Printed material" was not circled as having been provided to the patient. There was no documentation that information regarding the two psychoactive medications and their side effects was supplied to the patient in Spanish. The medication consent forms for each of these two medications was in English.

The patient had already received his first dose of "Depakote sprinkle" 250 mg twice daily on 7/17/18 - three days prior to the "verbal consent." He continued to receive it through the date of his discharge on 7/25/18.

The patient had already received his first dose of Seroquel 12.5mg/25mg on 7/18/18 - two days prior to the "verbal consent." He continued to receive it through the date of his discharge on 7/25/18.


All of the above findings were discussed in an interview with the Staff #1, facility administrator, on the afternoon of 8/16/18 in the facility conference room. No additional evidence of facility compliance was submitted.